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Carroll County Memorial HospitalMedical Staff BylawsRules & RegulationsMEDICAL STAFF BYLAWSMedical Staff approval: July 11, 2017Governing Board approval: November 28, 2017Revised and approved by Med Staff on December 3, 2019, Governing Board approval February 25, 2020Page 1 of 130
Table of ContentsPREAMBLE . 6DEFINITIONS. 6ARTICLE I NAME . 9ARTICLE II MEDICAL STAFF PURPOSES AND RESPONSIBILITIES . 92.1 Purposes. 92.2 Responsibilities . 9ARTICLE III MEMBERSHIP . 123.1 Nature of Membership. 123.2 Qualifications for Membership. 123.3 Duration of Appointment . 153.4 Procedures for Appointment and Reappointment . 153.5 Contract Practitioners . 153.6 Leave of Absence . 153.7 Illness and Impairments. 163.8 Obligations of Medical Staff 17ARTICLE IV MEDICAL STAFF CATEGORIES . 184.1 Categories . 184.2 Active Medical Staff. 184.3 Consulting Medical Staff . 194.4 Hospitalist. .204.5 Courtesy Medical Staff . 214.6 Emergency Medical Room Staff . 214.7 Locum Tenens Medical Staff . 224.8 Provisional Period . 22ARTICLE V ALLIED HEALTH PROFESSIONAL. 245.1 Allied Health Professional Staff . 24ARTICLE VI APPLICATION, APPOINTMENT, & REAPPOINTMENT . 266.1 General . 266.2 Pre-application. 26MEDICAL STAFF BYLAWSMedical Staff approval: July 11, 2017Governing Board approval: November 28, 2017Revised and approved by Med Staff on December 3, 2019, Governing Board approval February 25, 2020Page 2 of 130
6.3 Application . 276.4 Application Contents . 276.5 Effect of Signing and Submitting Application . 296.6 Burden of Providing Information . 306.7 Processing Application . 306.8 Credentialing . 326.9 Appointment . 356.10 Reappointment. 376.11 Application for Privileges as Allied Health Practitioner . 39ARTICLE VII DELINEATION OF CLINICAL PRIVILEGES . 417.1 Exercise of Privileges . 417.2 Basis for Privilege Determinations . 417.3 Responsibility in Defining Privileges . 417.4 Consultation and Other Conditions . 427.5 Requests. 427.6 Procedure . 427.7 Special Conditions for Dentists . 427.8 Special Conditions for Podiatrists . 437.9 Special Conditions for Allied Health Professional Staff . 437.10 Emergency, Disaster Privileges . 437.11 Temporary Privileges . 457.12 Telemedicine Privileges . 45ARTICLE VIII CORRECTIVE ACTION . 498.1 Grounds for Corrective Action . 498.2 Procedure . 498.3 Temporary Suspension of Privileges . 528.4 Summary Suspension . 538.5 Automatic Suspension . 53ARTICLE IX HEARING & APPELLATE REVIEW PROCEDURES . 599.1 Purpose . 59MEDICAL STAFF BYLAWSMedical Staff approval: July 11, 2017Governing Board approval: November 28, 2017Revised and approved by Med Staff on December 3, 2019, Governing Board approval February 25, 2020Page 3 of 130
9.2 Right to Hearing . 599.3 Initiating of Fair Hearing . 619.4 Hearing Procedure . 649.5 Appellate Review . 679.6 General Provisions . 71ARTICLE X OFFICERS . 7210.1 Officers of the Medical Staff . 7210.2 Term of Office . 7210.3 Qualifications of Officers . 7210.4 Election of Officers . 7210.5 Vacancies in Office . 7310.6 Removal of Officers . 7310.7 Duties of Officers . 74ARTICLE XI COMMITTEES . 7711.1 Organization of Committees. 7711.2 Clinical Service Committee . 7711.3 Medical Staff Committee . 7811.4 Credentialing Committee. 8011.5 Quality Improvement/Risk Management Committee. 8111.6 Utilization Review Committee . 8311.7 Infection Control Committee . 8411.8 Pharmacy and Therapeutics Committee . 8511.9 Peer Review Committee . 96ARTICLE XII MEDICAL STAFF MEETINGS . 8812.1 Annual Meeting . 8812.2 Regulation Meetings. 8812.3 Special Meetings . 8812.4 Attendance at Meetings by Active Medical Staff Members . 8812.5 Agenda. 89ARTICLE XIII CLINICAL SERVICES . 90MEDICAL STAFF BYLAWSMedical Staff approval: July 11, 2017Governing Board approval: November 28, 2017Revised and approved by Med Staff on December 3, 2019, Governing Board approval February 25, 2020Page 4 of 130
13.1 Unified, Integrated, Non-Departmental Medical Staff . 9013.2 Current Services; Affiliation . 9013.3 Physician Advisor; Election Qualifications and Appointment . 9013.4 Physician Advisor; Responsibilities and Authority . 9113.5 Service Functions . 91ARTICLE XIV RULES AND REGULATIONS . 93ARTICLE XV INTERPRETATION . 94ARTICLE XVI ADOPTION AND AMENDMENT . 9516.1 Adoption . 9516.2 Amendment . 95MEDICAL STAFF RULES AND REGULATIONS . 96ARTICLE I PROVISION OF PATIENT CARE .96ARTICLE II MEDICAL RECORDS . 116ARTICLE III RESTRAINTS AND SECLUSION . 124ARTICLE IV DEATH AND AUTOPSIES . 127ARTICLE V MEDICAL STAFF CONDUCT . 129ARTICLE VI REVIEW AND REVISIONS .129MEDICAL STAFF BYLAWSMedical Staff approval: July 11, 2017Governing Board approval: November 28, 2017Revised and approved by Med Staff on December 3, 2019, Governing Board approval February 25, 2020Page 5 of 130
BYLAWS OF THE MEDICAL STAFF OFCARROLL COUNTY MEMORIAL HOSPITALPREAMBLEWHEREAS, Carroll County Memorial Hospital is a not-for-profit corporation, organizedunder the laws of the State of Missouri for the purpose of providing health care, inpatientand outpatient medical services, and promoting the wellbeing of the citizens of CarrollCounty, Missouri and the surrounding area; andWHEREAS, the Governing Board of Directors of the Hospital has charged the MedicalStaff of the Hospital with the responsibility for providing, promoting, monitoring andimproving patient care in the Hospital; and to that end, the Medical Staff is continuallystriving to achieve quality patient care for patients of the Hospital and accepts and agreesto discharge its responsibilities subject to the ultimate authority of the Governing Board ofDirectors;NOW, THEREFORE, the Medical Staff, as hereinafter organized and comprised,practicing in the Hospital shall conduct their activities in conformity with these Bylaws tocarry out the functions delegated to the Medical Staff by the Governing Board of Directors.DEFINITIONSAs used in these Bylaws, unless the context clearly indicates otherwise, terms are definedas follows:1. Administrative Delinquency. A missing Practitioner or Allied Health Professionalsignature and/or date of signature, or other missing or incomplete information inmedical record documentation where such date or signature is required by law,regulations, conditions of participation, payer contract, and/or the policies, procedures,or Governing Documents of the Hospital but does not adversely affect the health orwelfare of a patient.2. CEO. The individual appointed by the Governing Board of Directors to act in its behalfin the overall management of the Hospital. This individual may, consistent with theHospital Bylaws, appoint a representative or designee to perform certain administrativeduties identified in Bylaws.3. Allied Health Professional. An individual, other than an individual who meets thefurther definition of “Practitioner” as defined herein, who provides direct patient careservices or assist Practitioners in the Hospital as authorized under these Bylaws andconsistent with the individual’s scope of practice under applicable law. Allied HealthProfessionals are not eligible for Medical Staff membership.MEDICAL STAFF BYLAWSMedical Staff approval: July 11, 2017Governing Board approval: November 28, 2017Revised and approved by Med Staff on December 3, 2019, Governing Board approval February 25, 2020Page 6 of 130
4. Applicant. A Physician, Dentist, or Podiatrist who requests to join the Medical Staffor to obtain Privileges at Hospital.5. Application. A request for initial appointment or reappointment to the Medical Staffas described in Article V of these Medical Staff Bylaws.6. Governing Board of Directors, Governing Board. The Governing Board of Directorsof Carroll County Memorial Hospital, organized pursuant to Title 19 Section 30-20.080of the Missouri Code of State Regulations.7. Certified Mail. Delivery by the United States Postal Service or by a commercialcarrier and that delivery is verified by a receipt.8. Clinical Privileges, Privileges. Permission granted to an individual, pursuant toArticle VI of these Bylaws, authorizing performance of specific diagnostic, therapeutic,medical, dental, or surgical services within the Hospital.9. Clinical Service, Service. A category of patient care designated in Article XI of theseBylaws.10. Corrective Action. The disciplinary measures set forth in Article VII.11. Dentist. An individual who has received a Doctor of Dental Medicine or Doctor ofDental Surgery degree and who has a Valid Unrestricted License to practice dentistryin the State of Missouri.12. Executive Council. The Hospital committee comprised of the Chief Executive Officer,Chief Operating Officer, Chief Nursing Officer, Chief Revenue Officer, Chief PeopleOfficer, and Chief Medical Officer.13. Governing Documents. The Hospital’s Medical Staff Bylaws, the Medical Staff Rulesand Regulations, the Hospital’s Corporate Compliance Plan, and the Hospital’s RiskManagement Plan.14. Hospital. Carroll County Memorial Hospital and its Governing Board of Directors,Executive Officers, Medical Staff, or departments, as the context may require.15. Medical Staff. The organized body of Practitioners who have been grantedmembership and have been granted Privileges to attend patients and/or to providediagnostic, therapeutic, medical, dental, or surgical Services in the Hospital.16. Medical Staff Committee. The Committee of the Active Medical Staff as set forth inArticle XI Section 11.3 of these Bylaws.17. Member. An individual granted membership to the Medical Staff of Carroll CountyMemorial Hospital pursuant to these Bylaws.MEDICAL STAFF BYLAWSMedical Staff approval: July 11, 2017Governing Board approval: November 28, 2017Revised and approved by Med Staff on December 3, 2019, Governing Board approval February 25, 2020Page 7 of 130
18. Physician. An individual with a Valid Unrestricted License to practice medicine andsurgery (M.D.), or osteopathic medicine and surgery (D.O.) through the MissouriGoverning Board of Healing Arts, within the State of Missouri, or in another state whenthe context clearly requires.19. Physician Advisor. An Active Member appointed pursuant to Article XIII Section13.3 of these Bylaws to oversee certain administrative aspects of his or her respectiveClinical Service.20. Podiatrist. An individual with a Valid Unrestricted License to practice podiatry(D.P.M.) through the Missouri Governing Board of Podiatric Medicine.21. Practitioner. An individual with a Valid Unrestricted License by the appropriateregulatory agency of the State of Missouri authorizing professional practice of aPhysician and surgeon (M.D.), osteopathic Physician and surgeon (D.O.), Podiatrist(D.P.M.), or Dentist (D.D.S.).22. Prerogative. The rights, by virtue of Medical Staff category or otherwise, granted to aMedical Staff Member, Practitioner or Allied Health Professional, and subject to theultimate authority of the Governing Board and the conditions and limitations imposedin these Bylaws and in other Hospital and Medical Staff policies.23. Special Notice. Written notice sent via Certified Mail, return receipt requested or byhand-delivery evidence by a receipt signed by the individual to whom it is directed.24. Valid Unrestricted License. An unexpired license to engage in professional activitieswithin the State of Missouri that is not limited on order of the licensing GoverningBoard in a manner which reduces the privilege to the exercise of all authority generallyassociated with a license.MEDICAL STAFF BYLAWSMedical Staff approval: July 11, 2017Governing Board approval: November 28, 2017Revised and approved by Med Staff on December 3, 2019, Governing Board approval February 25, 2020Page 8 of 130
ARTICLE I – NAMEThese Bylaws address the Medical Staff of Carroll County Memorial Hospital.ARTICLE II – MEDICAL STAFF PURPOSES AND RESPONSIBILITIES2.1 Purposes. The purposes of this organized, self-governing Medical Staff are to:A. Be accountable to the Governing Board for the appropriateness of patient careservices and the professional and ethical conduct of each Practitioner appointed tothe Medical Staff;B. Promote patient care at the Hospital that is consistent with generally recognizedstandards of care;C. Be the formal organizational structure through which the benefits of membershipon the Medical Staff may be obtained by individual Practitioners and theobligations of Medical Staff membership may be fulfilled;D. Provide an appropriate and efficient forum for Member input to the GoverningBoard and CEO on Hospital and medical issues; andE. Coordinate care, treatment, and services with other providers and Hospitalpersonnel.2.2 Responsibilities. The Medical Staff’s responsibilities shall include to:A. Participate in the performance improvement/quality assurance, quality review, andutilization management of the Hospital and conducting activities required by theHospital to assess, maintain, and improve the quality and efficiency of medical carein the Hospital, including without limitation:1. Evaluating Practitioner and institutional performance through use of a validsystem of measurement as developed by the Hospital, and based uponclinically sound criteria;2. Monitoring critical patient care practices on an ongoing basis;3. Establishing criteria and evaluating Practitioner credentials for appointmentand reappointment to the Medical Staff, and for identifying the ClinicalPrivileges that are assigned to individual Practitioners and Allied HealthProfessionals in the Hospital;4. Initiating and pursuing Corrective Action, with respect to Practitioners,when warranted;5. Identifying and advancing the appropriate use of Hospital resourcesavailable for meeting patients’ medical, social, and emotional needs, inaccordance with sound resource utilization practices;MEDICAL STAFF BYLAWSMedical Staff approval: July 11, 2017Governing Board approval: November 28, 2017Revised and approved by Med Staff on December 3, 2019, Governing Board approval February 25, 2020Page 9 of 130
B. Make recommendations to the Governing Board regarding Medical Staffappointment and reappointment, including category and Clinical Serviceassignments, Clinical Privileges, and Corrective Action or disciplinary action, asappropriate;C. Assist in the development, delivery, and evaluation of continuing medicaleducation and training programs;D. Develop and maintain Medical Staff Bylaws, Rules and Regulations, and policiesthat promote sound professional practices, organizational principles, andcompliance with federal and state law requirements;E. Enforce compliance with such Medical Staff Bylaws, Rules and Regulations,policies, and laws;F. Participate in the Hospital’s long-range planning activities;G. Assist in identifying community health needs;H. Participate in developing and implementing appropriate institutional policies andprograms to meet those needs;I. Fulfill the obligations and appropriately use the authority granted in these MedicalStaff Bylaws in a timely manner through use of Medical Staff officers, committeesand individuals and to account to the Governing Board;J. Ensure that at least one Physician Member shall be on duty or available within areasonable period of time for emergency service at all times;K. Ensure timely completion of medical records by a Practitioner in accordance withstate law and Hospital policy, including but not limited to documentation of:1. A medical history and physical examination completed no more than thirty(30) days before or twenty-four (24) hours after admission, but prior to anysurgery requiring anesthesia services. If the history and physicalexamination is documented prior to admission, an updated history andphysical examination are recorded within twenty-four (24) hours ofadmission, but prior to any surgery or procedure requiring anesthesia;2. Discharge summaries and all other required records within thirty (30) daysof discharge or dismissal;L. Perform any Medical Staff, committee, and/or Hospital functions for which theyare responsible;M. Abide by generally recognized standards of ethics and professional conductrelevant to their profession and specialty;MEDICAL STAFF BYLAWSMedical Staff approval: July 11, 2017Governing Board approval: November 28, 2017Revised and approved by Med Staff on December 3, 2019, Governing Board approval February 25, 2020Page 10 of 130
N. Satisfy continuing education requirements established by the Medical Staff;O. Maintain as confidential all information and documents related to patients’conditions or treatment, peer review, performance improvement and evaluation,risk management, utilization review, and other information related to the evaluationof the provision of health care, or actions or conduct of health care providers;P. Service on-call and interpretation rosters by assisting the CEO, who has the finalauthority, concerning what on-call and interpretation rosters will be utilized by theHospital, the criteria for serving on-call or interpretation rosters, and the schedulefor service on all call and interpretation rosters. The Governing Board may requirethe Members to serve on the on-call rosters as a condition of Medical Staffmembership if determined that such action is necessary to meet the needs of theHospital and the community it serves. The Governing Board may also permitMembers to be exempt from the on-call roster. Any Practitioner providing serviceson an on-call roster may be removed at any time by the CEO, after consulting withthe President of the Medical Staff (“President”) or Chair of the Governing Boardof Trustees (“Governing Board Chair”), if it is determined that it is in the bestinterests of the Hospital, the Medical Staff, or patient care to do so. Requiringservice on, or removal from, an on-call roster shall not be considered to be areduction or change in Privileges nor an Adverse Action concerning thePractitioner’s Privileges or Medical Staff membership. No Practitioner shall beentitled to a hearing or any appeal procedures as a result of the failure of thePractitioner to be appointed to or the removal of the Practitioner from any roster foron-call services or interpretation of tests or special procedures.Q. A Member’s failure to fulfill any of the aforementioned responsibilities or otherobligations as described in these Bylaws may be grounds for denial ofreappointment to the Medical Staff, reduction in Medical Staff category, restrictionor revocation of Privileges, or other Corrective Action in a final action of theGoverning Board or grounds for a hearing under Article VIII.MEDICAL STAFF BYLAWSMedical Staff approval: July 11, 2017Governing Board approval: November 28, 2017Revised and approved by Med Staff on December 3, 2019, Governing Board approval February 25, 2020Page 11 of 130
ARTICLE III – MEMBERSHIP3.1 Nature of Membership.A. No individual, including a person with a contract of employment with the Hospital,may admit or provide any health care services to patients in the Hospital unless thatindividual is a Member or has been granted Clinical Privileges in accordance withthe procedures set forth in these Medical Staff Bylaws.B. Medical Staff appointment shall confer only the Clinical Privileges andPrerogatives granted by the Governing Board in accordance with these Bylaws.C. No Applicant shall be denied membership on the basis of sex, race, creed, color,national origin, age, or a handicap unrelated to the ability to fulfill patient care andrequired Medical Staff obligations.D. No Practitioner shall be entitled to Medical Staff membership or to exerciseparticular Clinical Privileges at the Hospital merely because he or she:1. Holds a license or obtained a professional degree recognized by the State ofMissouri;2. Belongs to any particular professional organization;3. Holds a particular certification or fellowship, completed a program of residencytraining, or is a member of a specialty Governing Board, society, or body;4. Has previously had Medical Staff membership or Privileges in this Hospital;5. Is a current or former Member or holds or has held Privileges in any otherhospital or other health care f
Carroll County Memorial Hospital Medical Staff Bylaws Rules & Regulations . MEDICAL STAFF BYLAWS Medical Staff approval: July 11, 2017 Governing Board approval: November 28, 2017 Revised and approved by Med Staff on December 3, 2019, Governing Board approval February 25, 2020 Page 2 of 130 .
